Provider Demographics
NPI:1457797854
Name:HARKINS, SHANE M (LCSW)
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:M
Last Name:HARKINS
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3580 VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82604-4906
Mailing Address - Country:US
Mailing Address - Phone:307-267-1792
Mailing Address - Fax:
Practice Address - Street 1:1300 E A ST STE 201
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-2252
Practice Address - Country:US
Practice Address - Phone:207-235-3333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-13
Last Update Date:2020-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYLCSW-8391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY135466300Medicaid